House Republicans on Thursday narrowly passed a controversial bill to overhaul the nation’s health-care system, claiming a major victory even as the measure faces an uncertain fate in the closely divided Senate.

Under intense pressure to show they can govern and to make good on their promise to repeal and replace the Affordable Care Act, Republicans pushed the bill through after adopting a last-minute change that earned it just enough votes to pass. However, the House version fell significantly short of the GOP’s long-held goals, making major dents in large portions of the current law but not outright repealing it.

The bumpy, months-long process that led to Thursday’s vote also violated some of the GOP’s promises on how it would govern.

The measure proceeded without the benefit of an analysis from the Congressional Budget Office of its cost and impact on insurance coverage, and it did so after many Republicans openly acknowledged that they hadn’t read the bill. President Trump also promised “insurance for everybody,” which the measure will not achieve.

The American Health Care Act, which passed by a vote of 217 to 213, nonetheless represented a significant if incomplete political victory for Trump, who has struggled to secure legislative wins early in his presidency. The vote was also an important win for House Speaker Paul D. Ryan (R-Wis.), who has spent years trying to dismantle Obamacare but has struggled in recent months to unite an ideologically divided caucus.

(Daron Taylor/The Washington Post)

Power shifts to states

The House bill would shift power to states to set important health insurance rules. And it would end the ACA’s subsidies for eligible people who buy health plans through marketplaces created under the law, creating and substituting new tax credits. The measure also would rescind several taxes that have helped pay for the law, including ones imposed on Americans with high incomes, health insurers, medical devices and tanning salons.

Among the bill’s more contentious provisions is one that would allow states to let insurers return to their old practice of charging more to customers with preexisting medical problems — a practice that the current law prohibits.

Republicans claimed credit for taking a first step toward meeting their promise with a televised celebration in the White House Rose Garden — which Trump attended after postponing a long-planned event in New York with Australian Prime Minister Malcolm Turnbull to commemorate the 75th anniversary of the Battle of the Coral Sea.

“We’re going to get this passed through the Senate — I’m so confident,” Trump said.

Democrats, however, held their own celebration of sorts immediately after the vote, waving to Republicans on the House floor and chanting, “Hey, hey, hey, goodbye” — an apparent taunt suggesting that Republicans would lose elections next year as a result of the vote.

Before the vote, House Minority Leader Nancy Pelosi (D-Calif.) noted that while many Americans can’t name their member of Congress, Thursday’s vote would earn their ire.

“You will glow in the dark on this one,” Pelosi warned. “So don’t walk the plank, especially unnecessarily.”

The political positioning over the bill started immediately, with the GOP claiming that it would lower premiums and increase access to health insurance and Democrats casting it as a huge transfer of wealth because it would eliminate many of the taxes imposed under the Affordable Care Act, including on wealthy Americans.

Every Democrat and 20 Republicans voted against the measure, the latter a mix of ardent conservatives upset that the bill didn’t fully repeal Obamacare and members from suburban swing districts worried about the political fallout. The wide-ranging interpretations of whether the bill would gut the current law — or wouldn’t — are likely to fuel the nature and intensity of that fallout.

For instance, the measure does not eliminate the ACA’s requirement that most Americans carry health insurance, although the penalty for not having coverage would be erased. In its place, insurers would be allowed to charge 30 percent higher premiums for one year to customers who have had a gap in coverage of roughly two months or more.

Medicaid would also be transformed in two ways. For the 31 states that expanded the safety-net program under the ACA to include people with slightly higher incomes, the government would immediately stop paying for anyone new to enroll under the expansion and would eventually stop the extra federal money that came with the expansion. Starting in a few years, Medicaid would also end its half-century tradition as an entitlement program in which the government pays a certain share for each person who enrolls, switching instead to a “cap” with a fixed amount per person.

The vote capped a haphazard, months-long process that began before Trump’s inauguration but quickly became mired in intraparty disagreement over how Republicans should make good on the campaign promise they had been running — and winning — on since 2010, when then-President Barack Obama’s signature domestic policy achievement became law.

In March, Ryan pulled an earlier version of the measure after it became clear that he did not have the votes to pass it — primarily because of strong opposition from the conservative House Freedom Caucus.

After a two-week Easter recess, however, negotiations resumed, and Republicans came up with a new proposal that garnered support from Freedom Caucus members by allowing states to eliminate parts of the ACA that require insurers to include specific “essential health benefits” in health plans sold to individuals and small business and to set their own coverage requirements or none at all. The new version also added the language affecting customers with preexisting medical conditions.

The new proposal, however, threatened support among members of the House’s more moderate Tuesday Group. That, in turn, prompted yet another tweak this week to add $8 billion to help people with preexisting conditions pay for their health-care costs.

The amendment prompted powerful objections from a wide range of health policy experts and advocates, who questioned whether that amount of money was sufficient to help all the Americans who would need it.

Senators’ reservations

It also revived questions about the measure’s fate in the Senate, where widespread disagreement remains among Republicans about how to proceed on health care. First, the Senate’s parliamentarian — or rules-keeper — cannot review the legislation and determine the rules of debate until the CBO submits its official estimate, which could take several more weeks to complete, according to congressional aides. That would mean that official Senate debate on the bill could not begin until June.

Sen. John Cornyn (R-Tex.), the second-ranking Republican, declined to commit to a schedule for when the Senate will begin consideration of the House health care rewrite.

“There is no timeline,” he said. “When we get 51 senators, we’ll vote.”

But other senators made clear that the process would be more deliberative in the upper chamber of Congress.

“A bill — finalized yesterday, has not been scored, amendments not allowed, and 3 hours final debate — should be viewed with caution,” Sen. Lindsey O. Graham (R-S.C.) tweeted on Thursday before the House vote.

House Republicans insisted that they were not ramming their health-care bill through without giving members a chance to absorb it — as they accused Democrats of doing when the ACA was passed in 2010.

Democrats “put a 2,000-page bill on the table they knew no one had time to read, and we’re not doing that,” said Rep. H. Morgan Griffith (R-Va.).

“This is a rough-and-tumble exercise that the Founding Fathers anticipated,” he added.

House Freedom Caucus Chairman Mark Meadows (R-N.C.) said he was willing to abandon his previous demands that leaders allow hearings and discussion of the legislation because members had opportunities to weigh in on amendments over the past several days. The decision marked a measurable shift for hard-line Freedom Caucus members, who have insisted that leaders give them ample time to read legislation and weigh in before a bill comes up for a vote.

“I have read the bill no less than six times,” Meadows said. “If they haven’t read the bill, it is because they haven’t spent the time to do that.”

Republicans also disregarded the absence of a final estimate from the CBO — Congress’s official scorekeeper. Several said that last-minute changes to the legislation were unlikely to significantly change the final estimates.

Meadows, who struggled for weeks to rally his caucus around the measure, said the Senate will make changes he might not necessarily support.

Among other concerns, Republican senators from states that have expanded Medicaid under the ACA worry about rollbacks to that program included in the House bill. Then there’s a trio of conservative senators — Ted Cruz (R-Tex.), Mike Lee (R-Utah) and Rand Paul (R-Ky.) — who often buck GOP leaders. With a 52-48 advantage over Democrats, Senate Republicans have a smaller margin for error than their House counterparts.

The House measure may run into other procedural roadblocks in the Senate. The original proposal initially left many of the ACA’s insurance regulations alone — with the goal of ensuring it would pass muster with the Senate parliamentarian — but not all of them. The House’s version of the bill would undercut the ACA’s insurance regulations even more. That might make it difficult for Republican senators to pass the measure under a procedural maneuver known as “reconciliation,” which is usually reserved for budget legislation.

Because of a series of resignations, Republicans needed 216 votes to pass the bill but left nothing to chance. Even Rep. Jason Chaffetz (R-Utah), recovering from recent foot surgery, flew back to Washington against his doctor’s orders to vote for the bill.

“It was a big important vote, and it was close. I didn’t want to be the reason it failed,” Chaffetz told reporters.

While some Republicans were buoyant, others exhibited a palpable sense of relief that health care is off their plates — at least for now.

“It wasn’t fun,” Rep. Lou Barletta (R-Pa.) said.

Sean Sullivan, John Wagner, David Weigel, Kelsey Snell, Dino Grandoni, Elise Viebeck and Robert Costa contributed to this report.

Ed O'KeefeEd O’Keefe covered Congress and national politics for The Washington Post from 2008 to 2018. He has also covered federal agencies and federal employees in the Washington area, the war in Iraq, and the 2016 presidential campaigns of Jeb Bush and Marco Rubio. Follow

Paige Winfield CunninghamPaige Winfield Cunningham covers health policy and authors PowerPost's daily tipsheet The Health 202. She previously covered health-care for Politico, where she wrote the daily Pulse tipsheet. She has appeared on multiple media outlets including C-SPAN, CBS, MSNBC, Fox News, Fox Business and WJLA. Follow

Amy GoldsteinAmy Goldstein is The Washington Post’s national health-care policy writer. During her 30 years at The Post, her stories have taken her from homeless shelters to Air Force One, often focused on the intersection of politics and public policy. She is the author of the book "Janesville: An American Story." Follow